Provider Demographics
NPI:1558402735
Name:WILLIAM BOSTOCK , DO
Entity Type:Organization
Organization Name:WILLIAM BOSTOCK , DO
Other - Org Name:DR WILLIAM BOSTOCK & ASSOCIATES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-963-2967
Mailing Address - Street 1:771 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4386
Mailing Address - Country:US
Mailing Address - Phone:770-963-2967
Mailing Address - Fax:770-339-4585
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITE 255
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-963-2967
Practice Address - Fax:770-339-4585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACG0905OtherMEDICARE RAILROAD
GACG0905OtherMEDICARE RAILROAD
GAD28984Medicare UPIN
GAGRP4Medicare PIN
GAF76047Medicare UPIN